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C. Kick Detection Failure Possible Contributing Causes

On March 8, 2010, the Deepwater Horizon crew experienced a well control
event that went undetected for 30 minutes. Ten of the eleven individuals on
duty on March 8 during the undetected kick and well control event were also on
duty during the April 20 blowout. According to John Guide, Transocean rig
management personnel admitted to him that those individuals involved with the
March 8 incident had “screwed up by not catching” the kick. Although BP has
internal requirements to conduct investigations into all drilling incidents, BP did

not do so for the March 8incident. BP’s failure to perform an incident
investigation into the March 8, 2010 well control event and delayed kick
detection was a possible contributing cause to the April 20, 2010 kick detection
failure.

The Panel found no evidence that, during cement pumping, BP shared
information with either the Deepwater Horizon rig personnel or Transocean shore‐
based employees about the increased risks associated with the Macondo
production casing cement operations, such as, the decision not to include a
second cement barrier above the wiper plug and the anomalies encountered
during cement pumping. BP’s failure to inform the parties operating on its
behalf of all known risks associated with the Macondo well production casing
cement job was a possible contributing cause of the kick detection failure.

BP decided to combine two lost circulation material pills, and use this
combined material as a spacer in the Macondo well. The presence of this spacer
allowed viscous material to be across the choke and kill lines during the negative
test and possibly plugged the kill line. If the kill line was plugged, it could have
led to the pressure differential between the drill pipe and kill line. BP’s use of
the lost circulation material pills as a spacer in the Macondo well likely
affected the crew’s ability to conduct an accurate negative test on the kill line
and was a possible contributing cause of the kick detection failure.

John Guide, the BP well team leader, believed that the Deepwater Horizon
crew had become “too comfortable” because of its good track record for drilling
difficult wells. Ross Skidmore, a BP contractor on the rig on April20, testified

that the crew became complacent after completing drilling because “when you
get to that point, everybody goes to the mindset that weʹre through, this job is
done.” The complacency on the Deepwater Horizon could be attributable to the
crew not having access to all of the well data (OptiCem reports) available to BP
personnel onshore and the well site leaders on the rig. The overall complacency

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